Urinary tract infections (UTIs) are infections of the lower urinary tract (the urethra or the bladder). They are most common among young adults, especially women. Additional risk factors include sexual activity, use of diaphragms or spermicidal agents, menopause, and structural abnormalities of the urinary tract. Most infections are easily treated with antibiotics. If left untreated infections may ascend up the urinary tract to involve the kidneys leading to acute pyelonephritis.
Urinary tract infections typically occur when bacteria enter the urinary tract through the urethra and begin to multiply in the bladder. Although the urinary system is designed to keep out such microscopic invaders, these defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract. The most common UTIs occur mainly in women and affect the bladder and urethra.
Urinary tract infections don’t always cause signs and symptoms, but when they do they may include: a strong and persistent urge to urinate, a burning sensation when urinating, passing frequent and small amounts of urine, urine that appears cloudy, urine that appears red and bright pink or cola-colored — a sign of blood in the urine, strong-smelling urine, pelvic pain in women — especially in the center of the pelvis and around the area of the pubic bone.
One of the most important aspects of coding an acute UTI is documentation of site-specificity in the medical record.
Acute pyelonephritis: 590.1X, Acute pyelonephritis
Acute cystitis: 595.0, Acute cystitis
Urethritis: 597.80, Urethritis, unspecified
Code 599.0, Urinary tract infection, site not specified, should be assigned only if the physician has not identified or is unable to identify the site of the UTI.
Coding guidelines require the assignment of an additional code if the causative organism is identified. The UTI code is sequenced first, followed by the organism. E. Coli is a common organism causing UTIs and is reported with code 041.4.
If the documentation indicates that the UTI has progressed to sepsis, code 038.X should be assigned first, then code 995.91, Sepsis, followed by the appropriate UTI code. In this instance, sepsis indicates that the UTI has entered the bloodstream and becomes generalized sepsis. The systemic infection, sepsis, should be sequenced before the localized infection, UTI.
Recurrent or chronic UTI without current symptoms should not be coded to the acute infection. Code V13.02, Personal history of urinary (tract) infection, may be assigned to report this. Code V58.62, Long-term (current) use of antibiotics, may also be assigned if the patient is receiving prophylactic antibiotic therapy.
The table below includes the most commonly used ICD-10 Codes for UTIs:
|ICD-10 Chapter||Codes||Code Description|
|14||N30.00||acute cystitis without hematuria|
|14||N30.01||acute cystitis with hematuria|
|14||N30.10||Interstitial cystitis (chronic) without hematuria|
|14||N30.11||Interstitial cystitis (chronic)with hematuria|
|14||N30.20||Other chronic cystitis without hematuria|
|14||N30.21||Other chronic cystitis with hematuria|
|14||N30.30||Trigonitis without hematuria|
|14||N30.31||Trigonitis with hematuria|
|14||N30.40||Irradiation cystitis without hematuria|
|14||N30.41||Irradiation cystitis with hematuria|
|14||N30.80||Other cystitis without hematuria|
|14||N30.81||Other cystitis with hematuria|
|14||N30.90||Cystitis, unspecified without hematuria|
|14||N30.91||Cystitis, unspecified with hematuria|
|14||N34.3||Urethral syndrome, unspecified|
|14||N39.0||Urinary tract infection, site not specified|
|14||N39.9||Disorder of urinary system, unspecific|